Provider Demographics
NPI:1124163613
Name:BOU SERHAL, CHADI ELIAS (MD, MS)
Entity type:Individual
Prefix:DR
First Name:CHADI
Middle Name:ELIAS
Last Name:BOU SERHAL
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 TUSCARAWAS ST W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4644
Mailing Address - Country:US
Mailing Address - Phone:330-452-8844
Mailing Address - Fax:330-452-7012
Practice Address - Street 1:2600 TUSCARAWAS ST W
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4644
Practice Address - Country:US
Practice Address - Phone:330-452-8844
Practice Address - Fax:330-452-7012
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.086682207R00000X
OH35-086682207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2750321Medicaid
OH35.086682OtherOHIO LICENSE NUMBER
OHBO4221592Medicare PIN
OHBO4221591Medicare PIN